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Announcements: Access to specialty services via Referrals and Prior Authorizations

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Access to specialty services via Referrals and Prior Authorizations

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Ireland Army Community Hospital staff is fully dedicated to ensuring that all of our beneficiaries receive safe quality medical care. 

We understand that beneficiaries have concerns regarding how to access the specialty services that will shift to the network during the transition of IRACH services. We are here to support them throughout this transition and beyond, and they can be assured that there are processes in place to assist them. 

To get an appointment for specialty services within the network, patients will be given a referral. The referral process will work as follows:

Beneficiaries under the TRICARE Prime will continue to see their Primary Care Manager and the PCM will provide referrals to receive services from specialty care providers.


The referral management office at IRACH will coordinate the referral request with the regional contractor when necessary.  Our regional contractor for Tricare is Health Net Federal Services. Once the referral is “sent to HNFS” the beneficiary will receive an authorization letter in the mail within 7-10 days.


The authorization letter will have the name of the provider to which they have been referred. But if you prefer a different provider who is part of the Tricare network, you may request that provider. Once they receive the authorization they need to contact the provider shown on the authorization to book the appointment. The authorization is good for six visits and six months. The initial appointment must be booked within two months of receiving the authorization.


Active duty service members always require referrals for any and all civilian care.

For questions or concerns regarding the authorization letter the beneficiaries should contact 1-877-TRICARE (1-877-874-2273)

Beneficiaries that seek care, from a non-network TRICARE authorized provider without a referral from their PCM or prior authorization from the regional contractor, or from a network provider outside the TRICARE North region, are using the point-of-service option, resulting in higher out-of-pocket costs. For more information, visit www.tricare.mil/costs.


Prior Authorizations
Prior authorization is a review of the requested health care service to determine if it is medically necessary at the requested level of care. Some providers may contact the regional contractor to obtain prior authorization for the beneficiaries. 


For more information regarding prior authorization requirements, visit www.tricare.mil/authorization.


Active duty service members require prior authorization for all inpatient and outpatient specialty services. An additional fitness-for-duty review is required for maternity care, physical therapy, mental health care services, and family counseling.

For all other TRICARE Prime beneficiaries, the following services require prior authorization:

    Adjunctive dental services (i.e., dental care that is medically necessary in the treatment of an otherwise covered medical—not dental—condition)
    Extended Care Health Option services (Active duty military families only)
    Home health care services
    Home infusion therapy
    Hospice care
    Nonemergency inpatient admissions for substance use disorders or mental health care
    Outpatient mental health care beginning with the ninth visit per FY; certain types of mental health care services are excluded and always require a referral or prior authorization

Beneficiaries may contact IRACH Patient Services Center at (502) 624-0745 and ask for a beneficiary counseling and assistance coordinator or the Referral Management Office at 502-624-0713 for additional information.

Expires

 

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Created at 7/25/2016 3:53 PM by Tolliver, Rachael L Ms CIV USA MEDCOM IRACH
Last modified at 7/25/2016 3:53 PM by Tolliver, Rachael L Ms CIV USA MEDCOM IRACH